Overview
Intercostal neuralgia is a pain syndrome that occurs in the innervated area of the intercostal nerves and is mainly characterized by pain distributed along the intercostal bands. It is often caused by herpes zoster, pleurisy, or tumors.
What is intercostal neuralgia?
Definition of Intercostal Neuralgia
Intercostal neuralgia is a condition in which the intercostal nerve is damaged for various reasons, causing pain in the area it innervates.
It is a paroxysmal or persistent stabbing, burning pain that radiates in bands along the intercostal space to the front of the chest or abdomen.
There are 11 pairs of intercostal nerves, the 1st to 6th intercostal nerves are distributed in the chest, and the 7th to 11th intercostal nerves are distributed in the chest and abdomen.
Types
Primary intercostal neuralgia: rare, unknown cause, also known as idiopathic intercostal neuralgia.
Secondary intercostal neuralgia: more common, cause is clear.
Questions you may be concerned about
Can intercostal neuralgia be cured?
Some intercostal neuralgia can be cured.
Primary intercostal neuralgia is difficult to cure on its own, and the pain can be relieved or even cured with treatment.
The outcome of secondary intercostal neuralgia depends largely on the primary cause.
Intercostal neuralgia caused by herpes zoster may be cured if the autoimmune system is very strong; it is difficult to cure those who are physically weak and have weak immune system.
Intercostal neuralgia caused by thoracic spine tuberculosis and tumor is difficult to cure if the treatment is not timely or malignant, and may also lead to vertebral necrosis, deformity and paraplegia.
What are the common medicines used to treat intercostal neuralgia?
Commonly used medicines for intercostal neuralgia mainly include antiepileptic drugs, nutritive nerve drugs and antiviral drugs.
For people with severe pain, antiepileptic drugs can be applied, such as pregabalin and gabapentin, which can inhibit the abnormal discharge of nerves.
Nutritional nerve drugs such as vitamin B12, vitamin B1 or methylcobalamin are useful for nerve repair and pain relief.
If the intercostal neuralgia is caused by a virus, antiviral drugs such as acyclovir can be used.
Can CT detect intercostal neuralgia?
A CT scan helps to diagnose the cause of intercostal neuralgia.
Although the intercostal nerve cannot be seen directly, CT examination can detect the cause of intercostal neuralgia by looking at the tissue structures around the intercostal nerve, such as ribs and thoracic vertebrae, such as tumors in the spinal canal, herniated discs in the thoracic spine, tuberculosis in the thoracic spine, metastasis of thoracic vertebrae, and other lesions.
Metal objects worn on the body need to be removed before the CT examination to avoid artifacts affecting the imaging results.
Causes
Causes
The cause of primary intercostal neuralgia is unknown. Secondary intercostal neuralgia may be caused by the following factors.
Infectious or non-infectious inflammatory diseases
Infectious thoracic radiculitis, thoracic spondylitis, intercostal neuritis due to herpes zoster virus, etc.
Thoracic spine pathology
Thoracic scoliosis deformity, thoracic intervertebral disc herniation, thoracic vertebral osteophytes, ankylosing spondylitis, thoracic spinal tuberculosis, thoracic rib joint misalignment, rheumatoid arthritis, etc.
Tumor
Primary or metastatic tumors inside or outside the spinal canal, especially extramedullary tumors, often produce intercostal neuralgia due to compression of the nerve root.
Trauma
Rib fracture, post thoracic surgery, thoracic spine injury or post-surgery, etc.
Chest soft tissue damage
Fibrositis of the intercostal soft tissues, irritation of the tissue lesions around the thoracic vertebrae, and compression by scarring around the intercostal nerves.
Metabolic diseases
Diabetic peripheral neuropathy, osteoporosis, nephritis, etc.
Physical or chemical damage
Ethanol poisoning, direct injection of nerve-harming drugs onto the nerve, accidental electrocution and radiation injury, etc.
Predisposing factors
Intercostal neuralgia is easily triggered when the following factors are present.
Fatigue.
Immunocompromise.
Use of immunosuppressive drugs.
Risk factors
The following risk factors may be present for intercostal neuralgia caused by varicella-zoster virus infection.
Age
According to the 2016 Chinese Expert Consensus on the Diagnosis and Treatment of Postherpetic Neuralgia:
The incidence of postherpetic neuralgia in patients with herpes zoster over the age of 60 is 65%.
The incidence of postherpetic neuralgia in patients with shingles over the age of 70 is 75%.
The probability of postherpetic neuralgia in younger patients with shingles is very low.
Gender.
It is more likely to occur in women than in men.
Onset of herpes zoster
People who have significant pain before the appearance of herpes have an increased probability of developing postherpetic neuralgia.
The more severe the level of pain during the herpetic phase, the greater the probability of developing postherpetic neuralgia.
The longer and more numerous the duration of the blisters and the more extensive the lesions, the more likely postherpetic neuralgia is to develop.
Pathogenesis
The spinal cord and intercostal nerves, as a result of the above etiology, undergo a series of electrophysiological changes that lead to increased sensitivity of the receptive nerve endings.
This is manifested by abnormal sensitivity of tissues such as skin, muscle and bone to mechanical, physical, chemical and metabolic stimuli, resulting in spontaneous pain.
Symptoms
Prodromal symptoms
Intercostal neuralgia (postherpetic neuralgia) caused by the herpes zoster virus develops with prodromal symptoms such as low-grade fever, fatigue, and lack of appetite.
Main Symptoms
The main symptom is pain in the chest or abdomen.
The pain starts in the upper back and radiates along the intercostal space towards the anterior chest or abdomen in a semicircular band.
It is a paroxysmal or persistent stabbing, burning pain.
Deep inhalation, coughing or sneezing can trigger or worsen the pain, which is often characterized by a banding sensation (the chest feels like it’s being wrapped and tied up with bands).
When the pain is severe, it may radiate to the back of the shoulder on the same side.
Other symptoms
Some patients may experience numbness of the skin and involuntary muscle tremors.
Chronic severe pain is often accompanied by loss of appetite, restriction of activity, insomnia, and depression.
The skin in the area innervated by the lesioned intercostal nerve may be hypersensitive or hypersensitive, with pain on slight touching of the skin, or the skin may not easily feel heat, cold, vibration, or pins and needles.
Consultation
Department of Medicine
Neurology
If you experience chest or abdominal pain, especially if you feel that the pain is distributed along the intercostal area, it is recommended that you consult a doctor promptly.
Preparation for medical treatment
Preparing for your visit: registering, preparing your documents, FAQs
Tips
Avoid self-medicating with painkillers before going to the doctor to avoid aggravating the symptoms or masking the condition.
Preparation Checklist
症状清单
What is the location of the pain? How long has the pain lasted?
What are the characteristics of the pain?
Under what circumstances is the pain aggravated or alleviated?
病史清单
Has there been any chest trauma?
Are there any tumors, diabetes, herpes zoster, ankylosing spondylitis, or other diseases?
检查清单
Thoracic spine X-ray, thoracic spine magnetic resonance imaging, thoracic spine CT
用药清单
Analgesics: Ibuprofen, Carbamazepine, Amitriptyline, Gabapentin, Pregabalin
Others: vitamin B1, methylcobalamin, acyclovir
Diagnosis
Diagnosis based on
Medical history
History of chest trauma, tumor, or herpes zoster.
Clinical manifestations
Symptoms
Chest or abdominal pain radiating from back to front, along the intercostals.
It is a burning or stabbing pain.
Pain worsens with deep inhalation, coughing, or sneezing.
Physical Signs
The doctor may press on the area between the ribs, which, if it causes pain, suggests possible intercostal neuralgia.
The doctor will also perform a detailed neurologic examination to determine if there are any neurologic problems.
Imaging
X-rays can help detect conditions such as changes in the thoracic spine and ribs, tuberculosis of the thoracic spine, and metastatic cancer of the thoracic spine.
CT scans or MRI scans help to detect lesions in the spinal canal. It is especially suitable for those who have no changes on X-ray but have significant pain, and can confirm the diagnosis of thoracic disc herniation, thoracic spinal cord tumor and other intravertebral canal lesions.
Metal objects worn on the body need to be removed before the examination.
Other tests
Erythrocyte sedimentation rate and human leukocyte antigen (HLA)-B27 are tests that help diagnose intercostal neuralgia caused by rheumatic diseases.
Tumor markers, which help to screen for intercostal neuralgia caused by tumor metastasis.
Serologic tests, which help in the diagnosis of postherpetic intercostal neuralgia.
Differential diagnosis
Costochondritis
Similarities: Chest pain.
Differences: the site of pain in costochondritis is more limited, with significant localized swelling and tenderness, aggravated by activity or exertion. Intercostal neuralgia is usually distributed along the intercostal nerves in the same direction as the ribs.
Limited Pleurisy
Similarities: Persistent chest pain, aggravated by breathing and coughing.
Differences: The pain in limited pleurisy tends to be radiating and may extend to the abdomen, neck, or scapula. Chest pain may be relieved in limited pleurisy and worsened in intercostal neuralgia when pressure is applied to the painful area.
Tip of the rib syndrome
Similarities: Chest pain.
Difference: Tip of the rib syndrome is a poorly fixed anterior end of the 8th, 9th, and 10th ribs that manifests as a persistent stabbing, burning pain that radiates to the back and worsens with respiratory movements. It can be distinguished by examining the anterior ends of the 8th, 9th and 10th ribs for tenderness and mobility.
Treatment
Treatment aims and principles
Treatment purpose: Relieve pain, improve pain-induced insomnia, activity limitation and other manifestations, and improve the quality of life.
Treatment principle: When the pain is severe, analgesic drugs can be used to relieve it. For complete cure and total elimination of symptoms, treatment of the primary disease is also required.
Treatment Methods
Medication
Drug treatment is mainly aimed at analgesia.
Analgesic drugs
Carbamazepine: it has anti-neuralgia effect and can be used for post-herpetic neuralgia.
Amitriptyline: can relieve chronic pain. Note that it should not be used in combination with monoamine oxidase inhibitors and should be used only 14 days after discontinuing monoamine oxidase inhibitors.
Gabapentin: has anti-neuralgic effects and can be used for post-herpetic neuralgia. It is more effective in elderly patients over 75 years of age than in younger patients at the same dose. If discontinuation is needed, it is recommended that it be tapered off over a period of at least 1 week.
Pregabalin: May be used to treat postherpetic neuralgia. If discontinuation is needed, it is recommended that it be tapered off over a period of at least 1 week.
Ibuprofen: Relieves acute mild to moderate pain.
Non-opioid central analgesics: effective for acute and chronic pain. Do not drink alcohol while taking the medication.
Morphine: used for acute moderate to severe pain. It is addictive and should not be used for more than 8 weeks.
B vitamins
Assist in the treatment of peripheral neuropathy, nutritional nerve, commonly used vitamin B1, methylcobalamin, etc.
Antiviral drugs
For those caused by herpes zoster virus infection, antiviral drugs such as acyclovir can be given.
Precautions for drug use
All drugs need to be used under the guidance of a professional doctor, do not listen to folk remedies and secret prescriptions.
During the period of taking analgesic drugs, pay attention to observe the adverse reactions of the drugs, especially to observe whether there is gastrointestinal bleeding (symptoms such as vomiting blood, black stools, etc.). If adverse reactions occur, stop the drug immediately and inform your doctor promptly.
Physical therapy
Transcutaneous electrical stimulation has a good analgesic effect, especially for postherpetic neuralgia.
The efficacy of ultraviolet light, ultrasound, ultrashort waves and microwaves is not widely recognized.
Nerve block therapy
Pain point blocking therapy
Applicable people: localized obvious pressure and pain points, suspected that the intercostal nerve is locally pulled, stimulated or pressed, such as old rib fracture pain points, intercostal incision pain points after chest surgery.
Operation method: inject 1% lidocaine or 0.25% bupivacaine analgesic solution into the pain point.
Intercostal nerve block
Applicable location: Any part of the intercostal nerve course can be blocked, but the commonly used blocking sites are the angle of the ribs and the posterior axillary line.
Operation method: Intercostal block is mostly performed under ultrasound guidance. It is usually performed lying on the bed with the arms above the head and a pillow cushion under the abdomen, or in a sitting or side-lying position.
Epidural cavity block
Epidural blocks are a safe and effective block for those who have difficulty recognizing radicular or peripheral intercostal neuralgia.
Nerve destruction therapy
If the nerve block treatment is effective but the analgesic effect is not maintained for a long time, nerve destruction treatment can be used.
Intercostal nerve destruction by radiofrequency thermocoagulation
The operation method is similar to single intercostal nerve block.
For patients with mild disease and short course, pulse radiofrequency can be used for the first time, and some patients can achieve effective analgesia.
This method preserves all sensory and motor functions of the skin.
Chemical nerve destruction of the intercostal nerve
For severe and stubborn postherpetic intercostal neuralgia, or intercostal neuralgia caused by metastatic cancer of thoracic spine, permanent chemical destruction of corresponding nerve roots or nerve trunks can be carried out, and the analgesic effect is satisfactory.
Some patients may have localized swelling and pain after treatment, which can be gradually relieved after intermittent cold application with ice packs.
Thoracic nerve dorsal root ganglion destruction treatment
If the tumor has metastasized to the chest wall and invaded the intercostal nerve causing severe pain in the chest wall, the treatment of dorsal root ganglion destruction of the thoracic nerve can effectively control the pain in the chest wall.
Surgical treatment
Applicable people: For those who are not effective in radiofrequency thermocoagulation nerve destruction or chemical nerve destruction, intercostal nerves, spinal nerve roots, sympathetic nerves and anterior lateral cord of the spinal cord in the area of lesion can be used for the treatment.
Treatment effect: Primary intercostal neuralgia and incurable tumor-induced intercostal neuralgia often require multisegmental ganglionectomy for relief, but the effect varies greatly depending on the underlying disease and the location of the pain.
Prognosis
Cure
Intercostal neuralgia is difficult to cure on its own. After standardized treatment, it can be effectively relieved in 1 to 2 weeks, or even cured, but is prone to recurrence. The specific prognosis mainly depends on its primary disease.
Intercostal neuralgia caused by shingles
If one’s own resistance and immunity are so strong that one can eliminate the virus through one’s own immunity, then for this group of people, it is possible to heal themselves.
For patients with weak body and weak immunity, especially the elderly, the condition is likely to continue to deteriorate if they do not take medication.
Intercostal neuralgia caused by thoracic spine tuberculosis
If the treatment is not timely it will lead to necrosis of the vertebrae and deformity, which can seriously lead to paraplegia.
Intercostal neuralgia due to tumor
The prognosis is related to the condition of the tumor.
Harmfulness
Pain seriously affects normal life, study, social life, diet and sleep, resulting in a significant decline in the quality of life, and further psychosocial problems such as anxiety, depression and mania can occur.
Daily
Daily management
Dietary management
Patients without other diseases should ensure a diversified diet, and if there is a combination of other diseases, the diet should be under the guidance of the doctor.
Diet should be light (less oil, less salt, less sugar), avoiding spicy and stimulating foods such as chili, pepper, coffee and curry.
Increasing the intake of fresh vegetables and fruits in moderation can help nourish the nerves and relieve pain and inflammation.
It is recommended to prioritize the consumption of fish and poultry for meat, and deep-sea fish can be consumed in moderation to reduce the intake of red meat such as pork and beef.
Drink plenty of warm boiled water. Adults should ensure a daily water intake of 1,500 to 1,700 milliliters.
Alcohol is strictly prohibited during pain episodes and is not recommended during periods of remission.
Limit the intake of sugary drinks and desserts.
Lifestyle management
Regular work and rest, less staying up late.
Relax, avoid excessive stress and mental tension.
Nursing care for primary disease
Intercostal neuralgia caused by shingles
Do not scratch herpes.
Apply medication as prescribed by the doctor.
Intercostal neuralgia caused by thoracic spine tuberculosis
Pay attention to rest and nutrition.
Reduce the activities, if necessary, follow the doctor’s advice of strict bed rest.
Intercostal neuralgia caused by thoracic tumor
Apply ice chips and peppermint oil to the painful location to help relieve pain.
Eat small meals, take rest and exercise properly.
Family management
Family members should pay attention to observe the patient’s condition, especially for elderly patients. Analgesic drugs can be applied appropriately to help sleep when the pain increases at night.
Postherpetic neuralgia may last for a long time and often requires long-term treatment. Family members should help the patient to establish the belief of overcoming the disease and show more care, consideration and concern for the patient.
Prevention
Prevention mainly starts from preventing the original disease.
Vaccination against herpes zoster can prevent intercostal neuralgia caused by herpes zoster virus infection. The shingles vaccine is generally recommended for people over the age of 50.
Pay attention to safety and avoid trauma.
Actively treat diseases such as tuberculosis and tumors.